Eosinophilic pustular folliculitis associated with Sézary syndrome

immunosuppressed patient. Treatment with minocycline and trimethoprim–sulfamethoxazole failed, despite documented in vitro sensitivity of the organism to both agents. The patient eventually required surgical excision and a combination of meropenem and trimethoprim– sulfamethoxazole to clear the infections. Finally, cutaneous N. vinacea was described in an immunocompetent patient, who presented with a tender, purulent, erythematous plaque on his forearm. After failing treatment with oral cefditoren and topical potassium permanganate, the patient improved on amoxicillin–clavulanate. All of the patients had a history of outdoor exposure, emphasizing that Nocardia spp. are common isolates in soil. These cases highlight several key points in the diagnosis and management of primary cutaneous N. vinacea infection. A high level of suspicion for atypical infections must be maintained, and the diagnostic laboratory must be informed when Nocardia is considered, as it has specific culture and identification requirements. In addition, even in cases of proven in vitro sensitivity to particular antibiotics, N. vinacea may demonstrate in vivo resistance to those antibiotics, as demonstrated above. Appropriate treatment requires close follow-up and interdisciplinary management to achieve resolution.